Change of signs, symptoms and voice quality evaluations throughout a 3- to 6-month empirical treatment for laryngopharyngeal reflux disease.

OBJECTIVE: To assess the usefulness of voice quality measurements as a treatment outcome in patients with laryngopharyngeal reflux (LPR)-related symptoms. DESIGN: Prospective uncontrolled multi-centre study. MATERIAL AND METHODS: A total of 80 clinically diagnosed LPR patients with a reflux finding score (RFS)>7 and a reflux symptom index (RSI)>13 were treated with pantoprazole and diet recommendations during 3 or 6 months, according to their evolution. RSI; RFS; blinded Grade, Roughness, Breathiness, Asthenia, Strain and Instability (GRBASI) and aerodynamic and acoustic measurements were evaluated at baseline, 3 months (n = 80), and 6 months (n = 41) post-treatment. We conducted a correlation analysis between the adherence to the diet, and the evolution of both signs and symptoms and between videolaryngostroboscopic signs and acoustic measurements. RESULTS: Reflux symptom index, RFS, perceptual voice quality evaluations (dysphonia, roughness, strain and instability), and aerodynamic and acoustic measurements (ie, percent jitter and percent shimmer) were significantly improved at 3 months post-treatment but not at 6 months. Percent jitter was the most useful outcome for evaluating the clinical evolution of patients throughout the treatment course. A significant relationship between globus sensation and posterior commissure hypertrophy was documented; both seemed to significantly improve from 3 to 6 months. The correlation analysis revealed correlations between adherence to diet recommendations and the improvement of symptoms and between posterior commissure granulation severity and acoustic measurement impairments. CONCLUSION: Voice quality improved in a manner similar to both signs and symptoms throughout a 6-month empirical treatment with better improvement the 3 first months. Voice quality assessments can be used as indicators of treatment effectiveness in patients with LPR-related symptoms.

[Laryngeal involvements in systemic diseases : a discussion based on a case report.] / Manifestations laryngées des maladies de système : cas clinique.

Systemic diseases can affect the larynx. The most common laryngeal involvements, although often unknown, consist in inflammatory laryngitis, laryngeal ulcers, cricoarytenoid arthritis, recurrent laryngeal nerve paresis and subglottic stenosis. The clinical case we report is more uncommon, but representative of autoimmune diseases : vocal folds bamboo nodes in a young female patient, age 34, suffering from active rheumatoid arthritis. In the present article, we detail the current knowledge of this pathology and later discuss different laryngeal involvements of systemic diseases by lesion type et their management.

Les maladies de système peuvent affecter le larynx. Leurs manifestations laryngées les plus fréquentes, bien qu'elles soient souvent méconnues, sont les laryngites inflammatoires, les ulcères laryngés, les arthrites crico-aryténoïdiennes, les parésies récurrentielles et les sténoses sousglottiques. Le cas clinique que nous rapportons ici est plus rare, mais caractéristique des maladies auto-immunes : des noeuds de bambou des cordes vocales chez une jeune patiente de 34 ans souffrant d'une polyarthrite rhumatoïde. Dans cet article, nous détaillons les connaissances actuelles sur cette pathologie et discutons ensuite les différentes manifestations laryngées des maladies de système par type de lésion et leur prise en charge.

Health-related quality of life in Colombia: reference values of the EORTC QLQ-C30.

There are normative data of the quality of life (QoL) questionnaire EORTC QLQ-C30 (the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) for several European countries and Korea, but not for Latin America. The aim of this study was to provide these normative values for the general population in Colombia and to assess differences in terms of age and sex. For that reason, a sample of 1500 representatively selected individuals of the Colombian population completed the EORTC QLQ-C30 form. Results showed that mean scores of the Colombian population are similar to those obtained in European countries; whereas the mean values from a Korean study were lower (worse QoL). Age and sex differences were found in several scales and symptom items. Linear regression analyses were calculated to help quantify the influence of age and gender on QoL. Men reported better functioning and less symptoms than women on all scales, and older individuals reported worse global scores in terms of functioning and lower QoL than younger ones. In sum, the normative values presented can be used to assess QoL scores of Latin American cancer patients and to compare groups of patients with unequal age and sex distributions.

[Clinical vignette for the medical school student: jugular foramen syndrome]. / La vignette diagnostique de l'etudiant. Syndrome du trou déchiré postérieur (foramen jugulaire).

Cranial neuropathies are frequent and their semiological analysis is the basis of the diagnostic workup. This is even more true in the case of multiple cranial neuropathies. We here propose a diagnostic exercise in the case of a simultaneous cranial nerves IX (glossopharyngeal), X (vagus) and XI (spinal) deficit. This case exemplifies that knowledge of nervous anatomy and physiology is the basis of the semiology of the nervous system.

Spontaneous hemopneumothorax in an adolescent with COVID-19.

As coronavirus disease 2019 (Covid-19) continues to spread world-wide, new symptoms associated with the disease continue to appear. Common manifestations include fever, shortness of breath, and gastrointestinal illness. In addition, COVID is known to induce coagulopathy. Here, we present the case of a 17-year-old male who presented with a massive hemopneumothorax and was found to incidentally be positive for Covid-19. We suspect that he had a primary pneumothorax from a bleb and the hemothorax could've been induced by the coagulopathic state induced by COVID infection.

Laryngopharyngeal reflux disease in singers: Pathophysiology, clinical findings and perspectives of a new patient-reported outcome instrument.

PURPOSE OF REVIEW: Laryngopharyngeal reflux (LPR) is an inflammatory disease associated with the development of voice disorder and vocal fold lesions. The occurrence of LPR in professional voice users as singers can have a dramatic impact of daily life. The aims of this paper is to review the current literature about the pathophysiological mechanisms underlying the development of voice disorder, especially in singers, and to propose a new patient-reported outcome instrument to assess complaints of these patients. RECENT FINDINGS: Many clinical and experimental studies reported that LPR leads to the development of significant macroscopic and microscopic histological changes in the mucosa of the vibratory margin of the vocal folds. Epithelial cell dehiscence, microtraumas, Reinke's space modifications, inflammatory infiltrates, mucosal drying, and epithelial thickening are associated with LPR. These histological changes may modify the biomechanical properties of the vocal fold tissue leading to hoarseness. In practice, singers with LPR may have normal or discretely pathological speaking voice but impaired singing voice (vocal fatigue, hoarseness, and loss of range). To date, the literature about the specific LPR signs and symptoms in singers is almost non-existent. However, singers are at high risk to present LPR because of necessary air support involving higher intra-abdominal pressure, increased stress due to career management and uncomfortable schedules, late meals just before sleep, bad nutrition habits like increased intake of citrus products, fats foods and spicy foods. PERSPECTIVES: The lack of clinical singer-reported outcome instrument may decrease the management of LPR in singers. In this context, the LPR Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS) developed a new instrument to precisely assess symptoms related to LPR in singing voice. This instrument will be validated and could be used in clinical practice in voice centers.

The development of new clinical instruments in laryngopharyngeal reflux disease: The international project of young otolaryngologists of the International Federation of Oto-rhino-laryngological Societies.

INTRODUCTION: To analyze the epidemiological characteristics of placebo controlled randomized trials (RCTs) that evaluated the effectiveness of medical treatments over placebo in laryngopharyngeal reflux (LPR). MATERIAL AND METHODS: PubMed, Cochrane database, and Scopus were assessed for subject headings using the PRISMA recommendations. Placebo RCTs published between 1990 and 2018 describing clinical evolution throughout LPR treatment were extracted and analyzed for evidence-based level, number of patients, inclusion and exclusion criteria, gender, age, symptoms and signs used as therapeutic outcomes, and treatment schemes. RESULTS: The database search identified 15 placebo RCTs with a total of 763 patients. The mean age of patients was 48.59 years and 52.68% of patients were female. Among the 15 placebo RCTs, 9 have demonstrated a partial or total superiority of a medical treatment over placebo. Most of authors based the LPR diagnosis on symptoms and signs without additional examination. Our analysis reveals an important heterogeneity between studies with regard to the diagnosis criteria, treatment schemes and signs and symptoms used as therapeutic outcomes. Many commonly reported signs and symptoms related to LPR were not used as therapeutic outcomes. Half of the authors did not prescribe diet and behavioral changes along the treatment. CONCLUSION: The controversy in the RCTs about the superiority of medical treatment over placebo in LPR disease is probably due to discrepancies in the diagnosis method, exclusion criteria, therapeutic schemes and the lack of comprehensive tools for the assessment of signs and symptoms. In this context, the LPR Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies developed two new instruments to precisely assess signs and symptoms throughout the treatment. These two instruments could be used in future trials comparing medical treatment over placebo in LPR disease.

The effect of meconium exposure on the expression and differentiation of amniotic fluid mesenchymal stem cells.

BACKGROUND: The goal of this study was to determine if exposure to meconium would alter the phenotype of amniotic fluid mesenchymal stem cells (AF-MSCs) and the ability of these cells to be differentiated into distal airway type cells. METHODS: Meconium was collected, lyophilized and resuspended in PBS at 3 different concentrations (high, medium, and low). AF-MSCs were cultured in the presence of this meconium suspension for 8 hours and then analyzed for changes in gene expression. Additionally, AF-MSCs exposed to meconium were differentiated for 14 days using modified small airway growth medium (mSAGM) and gene expression was determined. As a spontaneous differentiation control, meconium exposed AF-MSCs were cultured in amniotic fluid stem cell medium (AF medium). RESULTS: After 8 hours of exposure in culture, AF-MSCs had increased expression of distal airway genes aquaporin 5 (AQP5) and surfactant protein c (SPC) when cultured in AF medium containing meconium. These gene expression levels were similar to that of AF-MSCs that were differentiated in mSAGM for 14 days. Furthermore, there was an up regulation of pluripotency genes NANOG and OCT4 in response to low meconium concentration for 8 hours. Following 14 days of culture in mSAGM, there was an upregulation of TTF1, SPC and AQP5 expression in the control, as well as in the low and medium meconium exposed groups indicating that these cells were still able to be differentiated. High meconium concentration did, however, appear to influence the level of distal airway gene expression after 14 days in mSAGM. After 14 days in AF medium, there was significant downregulation in pluripotency and mesenchymal markers as well as distal airway gene expression in all groups. CONCLUSION: The phenotype of AF-MSCs is modulated by meconium exposure; however, the cells were still able to differentiate into distal airway gene and protein expression. This result supports the hypothesis that progenitor cells exist in the amniotic fluid and the presence of meconium may affect their initial phenotype. However, these cells were still able to be differentiated to a distal lung phenotype.

Long-term Results of 18 Fat Injections in Unilateral Vocal Fold Paralysis.

OBJECTIVE: The purposes of this study were to assess the long-term efficacy of medialization laryngoplasty via injection of autologous fat in patients with unilateral laryngeal paralysis, and to discuss the results based on the volume of fat injected and the size of the initial glottic gap. STUDY DESIGN: This was a retrospective study with clinical reevaluation of 18 patients treated for unilateral laryngeal paralysis at Liège University Hospital between April 1, 2011, and December 1, 2014. METHOD: The voice examination included subjective scales (GRBAS and the Voice Handicap Index), a report on acoustic and aerodynamic voice parameters, and laryngostroboscopic assessment of glottic closure and mucosal wave (T0: preoperative; T1: immediate postoperative; T2: >1 year). RESULTS: The median follow-up duration was 19 months. We observed a significant improvement in maximum phonation time; mean flow rate; jitter; the Voice Handicap Index; the G, R, B, and A subscales of the GRBAS-I; and glottic closure at T1. These parameters remained stable over time, without any significant difference except for shimmer and glottic closure between T1 and T2. Regardless of the volume of fat injected and the magnitude of the initial glottic gap, we did not see any significant difference from one assessment time to another. CONCLUSION: Medialization laryngoplasty by means of the injection of autologous fat is a safe, effective surgical technique for patients with unilateral laryngeal paralysis regardless of the size of the initial glottic gap. The results are maintained longer than 1 year, and no evidence of significant resorption of the fat was found in our study over a period of 12-58 months. The volume of fat injected does not seem to affect the functional results.

Laryngeal dysfunction after thyroid surgery: diagnosis, evaluation and treatment.

Because of the close anatomical relationships between thyroid gland and laryngeal nerves, sensory-motor impairment of the laryngeal functions is a well known possible complication of thyroid surgery. Laryngeal nerve paralysis can present with various and often associated symptoms like dysphagia, aspiration, voice alteration or dyspnea. Several examination procedures are mandatory to perform a complete neuro-laryngeal evaluation: rigid and flexible video-stroboscopy will assess the abductor, adductor and tensor functions in breathing, sniffing, talking and eventually singing tasks. Laryngeal electromyography (LEMG), despite its technical difficulties, brings valuable objective and pronostic informations. Aerodynamic assessment of voice production and objective acoustic voice evaluation are important for patients' follow-up, especially for voice professionals like teachers and singers. Treatment of laryngeal sensory-motor nerve paralysis can be conservative, with the help of speech therapy. Early surgical treatment is indicated in cases with severe functional problems like aspiration pneumonia, disabling breathy hypophonia, ineffective cough, disabling dyspnea. Surgical therapy at 6 to 9 months after injury is indicated in patients who demonstrate evidence of denervation or little activity on LEMG and have a poor response to a reasonable trial of speech therapy. Many surgical procedures are available. Depending on the type of neuro-laryngeal deficit, the main and more widely used techniques are: injection laryngoplasty, medialization thyroplasty, arytenoid adduction, arytenoidopexy, crico-thyroid approximation, endoscopic laser cordotomy and re-innervation procedures.

Matrix metalloproteinase inhibitor prevents acute lung injury after cardiopulmonary bypass.

BACKGROUND: Acute lung injury (ALI) after cardiopulmonary bypass (CPB) results from sequential priming and activation of neutrophils. Activated neutrophils release neutral serine, elastase, and matrix metalloproteinases (MMPs) and oxygen radical species, which damage alveolar-capillary basement membranes and the extracellular matrix, resulting in an ALI clinically defined as adult respiratory distress syndrome (ARDS). We hypothesized that treatment with a potent MMP and elastase inhibitor, a chemically modified tetracycline (CMT-3), would prevent ALI in our sequential insult model of ALI after CPB. METHODS AND RESULTS: Anesthetized Yorkshire pigs were randomized to 1 of 5 groups: control (n=3); CPB (n=5), femoral-femoral hypothermic bypass for 1 hour; LPS (n=7), sham bypass followed by infusion of low-dose Escherichia coli lipopolysaccharide (LPS; 1 microgram/kg); CPB+LPS (n=6), both insults; and CPB+LPS+CMT-3 (n=5), both insults plus intravenous CMT-3 dosed to obtain a 25-micromol/L blood concentration. CPB+LPS caused severe lung injury, as demonstrated by a significant fall in PaO(2) and an increase in intrapulmonary shunt compared with all groups (P<0.05). These changes were associated with significant pulmonary infiltration of neutrophils and an increase in elastase and MMP-9 activity. CONCLUSIONS: All pathological changes typical of ALI after CPB were prevented by CMT-3. Prevention of lung dysfunction followed an attenuation of both elastase and MMP-2 activity. This study suggests that strategies to combat ARDS should target terminal neutrophil effectors.

[Vocal fold structure and speech pathologies]. / Structure cordale et pathologies vocales.

Our knowledge of vocal fold structure has profoundly evolved since the description by M. Hirano in 1974 of the laminar organization of the connective tissue of the human vocal fold, the lamina propria. The molecular composition of the extracellular matrix (ECM) of the lamina propria is essential in determining the viscoelastic properties of the tissue. This is particularly true in the superficial layer of the lamina propria (also called Reinke's space). With the epithelium, Reinke's space constitutes the vocal fold main vibrator. In normal subjects, the jelly like structure of the Reinke's space is due to a very loose fibrous scaffolding and to a balance between the interstitial proteins of the ECM: Proteoglycans like decorin and hyaluronic acid and glycoproteins like fibronectin. Vibratory trauma leads, in disease states, to molecular modification of the extracellular matrix of Reinke's space resulting in benign cordal lesions like nodules, submucosal fibrosis and vocal folds scars. Improving the knowledge of the homeostasis of Reinke's space ECM can lead to improvement of the therapeutic and prevention strategies of vocal fold benign lesions. The main histologic and viscoelastic characteristics, as well as surgical treatment of cordal nodular lesions and scars are described. The recent researches in the field of regeneration of Reinke's space are evoked.

Isospin tracing: A probe of nonequilibrium in central heavy-Ion collisions

Four different combinations of 9644Ru and 9640Zr nuclei, both as projectile and target, were investigated at the same bombarding energy of 400A MeV using a 4pi detector. The degree of isospin mixing between projectile and target nucleons is mapped across a large portion of the phase space using two different isospin-tracer observables, the number of measured protons and the tritium to 3He yield ratio. The experimental results show that the global equilibrium is not reached even in the most central collisions. Quantitative measures of stopping and mixing are extracted from the data. They are found to exhibit a quite strong sensitivity to the in-medium ( n,n) cross section used in microscopic transport calculations.

Multiple sequential insults cause post-pump syndrome.

BACKGROUND: We hypothesize that post-pump syndrome (PPS) following cardiopulmonary bypass (CPB) can be caused by multiple minor insults and that the mechanism of PPS is a priming and subsequent activation of polymorphonuclear (PMN) leukocytes. In this study extensive pathophysiologic and morphometric assessment was undertaken in a porcine model of sequential insult PPS. METHODS: Pigs were anesthetized, placed on a ventilator, instrumented for measurements of hemodynamic function, and separated into five groups: (1) Control (n = 4)--surgery only, (2) CPB (n = 4)--placed on femoral-femoral hypothermic (28 degrees C) bypass for 1 h, (3) LPS (n = 6)--underwent sham CPB followed by infusion of low dose endotoxin [E. coli lipopolysaccharide (LPS-1 microg/kg)], (4) Heparin + protamine + LPS (HP + LPS, n = 4)--were heparinized without CPB for 1 h, following which protamine and LPS were infused and (5) CPB + LPS (n = 8)--subjected to both CPB and LPS. RESULTS: Only CPB + LPS resulted in acute respiratory distress typical of PPS as indicated by a significant decrease in PaO2 and increase in intrapulmonary shunt fraction (p<0.05). CPB + LPS significantly increased tissue density and the number of sequestered monocytes and PMNs (p<0.05) above all other groups. Alveolar macrophages (AM) increased equally in all groups receiving LPS. CONCLUSIONS: CPB primes the inflammatory system causing pulmonary PMN sequestration without lung injury. Exposure to an otherwise benign dose of endotoxin results in activation of the sequestered PMNs causing PPS. This study confirms that PPS can be caused by multiple minor insults.

Venocutaneous fistula: a central venous catheter--associated complication.

Central venous catheter placement for parenteral feeding, whether short-term as in acute hospital care or long-term as in home total parenteral nutrition (TPN), is a well-established intervention in the patient who cannot eat. Access to the central venous system in the majority of the cases is gained by insertion of the catheter into either the subclavian or jugular vein. Associated with central venous catheters is the possible development of mechanical and septic complications, the incidence of which depends upon the skill, experience, and commitment of both the patient and the nutrition support team. A case report is presented in which a woman developed a venocutaneous fistula due to a chronic indwelling right internal jugular central catheter placed for long-term home nutritional support. The patient's medical history, management of her catheter, and proposed etiology for this problem are discussed, and complications of central access and TPN usage are addressed.

A novel diagnosis of left paraduodenal hernia through laparoscopy.

A congenital intraperitoneal hernia, also known as a "paraduodenal hernia," is an extremely rare cause of intestinal obstruction. These hernias, which are caused by variations in intestinal rotation, present with symptoms ranging from intermittent abdominal pain to acute obstruction. Preoperative diagnosis is rare, and conventional treatment is usually by laparotomy. Laparoscopic diagnosis and repair has recently been reported in Japan. We present as case of a left paraduodenal hernia diagnosed and treated laparoscopically and a review of the literature.

Primary lupus-associated protein-losing enteropathy.

A 79-year-old native American female with a history of diabetes mellitus, but no history of hepatic or renal disease, presented with anasarca and hypoalbuminemia. Laboratory tests for fecal alpha 1-antitrypsin and an indium III-labeled plasma transferrin nuclear scan revealed a protein-losing enteropathy. A serological test was positive for antinuclear antibody in a titer of 1:1250 with a homogeneous pattern. This finding combined with low normal serum complement levels suggested the diagnosis of systemic lupus erythematosus (SLE). This case is unusual in that protein-losing enteropathy was the only presenting symptoms. The late onset of this disease is also unusual.

Acute severe rhabdomyolysis in an human immunodeficiency virus-seropositive patient associated with rising anti-coxsackie B viral titers.

Very recently there have been sporadic reports of polymyositis in patients who are positive for human immunodeficiency virus (HIV). The cause of this condition has not been documented. Recent evidence has been presented which indicates that the Coxsackie B virus may be a causative factor. Presentation is made of a patient, a drug abuser who was found to be HIV-positive with severe polymyositis manifested by generalized muscle weakness and a total serum creatinine kinase that reached the unusually high level of > 600,000 U/L. This patient was found to have a rise in titer of Coxsackie B-4 virus antibodies. He was negative for a variety of possible infectious causes of this condition and was negative for both antinuclear antibodies (ANA) and rheumatoid factor (RF). It is concluded that a polymyositis may indeed be associated with immunosuppressed states and that Coxsackie B-4 virus may be an important causative factor.

Serum analyte pattern characteristic of fulminant hepatic failure.

Fulminant hepatic failure (FHF) is a poorly understood condition in which total liver failure occurs and is thought to be caused by a variety of conditions including Reye's syndrome, hepatitis, drug overdoses, and vascular insufficiency. While this condition is an uncommon one, it carries with it a high fatality rate and must therefore be diagnosed as rapidly as possible. Six patients have been observed over a two-year period with biopsy and/or autopsy-confirmed FHF: one with acute hepatitis B-delta; three with histories of alcoholism, two of them with cirrhosis; one with acute tylenol overdose; and one with hepatic vascular insufficiency. All of these patients, except one, exhibited a rapid, fatal downhill course after onset of symptoms. In all of these patients, a consistent elevation was observed in serum levels of aspartate aminotransferase (AST) or serum glutamate oxaloacetate transaminase (SGOT) and alanine aminotransferase (ALT) or serum glutamate pyruvate transaminase (SGPT) such that the ratio of AST to ALT was significantly greater than 1 and in serum levels of ammonia. Other liver function tests were found to be abnormal but not in so consistent a pattern, although total protein and albumin were found to be significantly decreased in all of these patients. The stereotypical elevation of the transaminases with high AST-to-ALT ratios and the rise in ammonia appear to characterize this life-threatening illness most reliably.

Presentation of carcinoma in a patient with a previous operation for Hirschsprung's disease.

The usual complications after a definitive pull-through procedure for Hirschsprung's disease include stricture formation, enterocolitis, bowel obstruction, and, occasionally, wound infection. The authors report a case of mucinous adenocarcinoma arising 32 years later at a stricture site from a previous pull-through procedure.